Maximum Plan Allowance (MPA) definition
Maximum Plan Allowance (MPA) means the maximum amount that the Plan will reimburse providers under the CityCore medical Benefit. For an In-Network provider, the MPA is the amount the provider has agreed to accept for a particular service. MPA for an Out-of-Network provider is based on the lesser of the amount payable under any supplemental provider fee arrangements the Third Party Administrator may have in place and the 75th percentile of fees commonly charged for a given procedure in a given area, based on the Ingenix MDR System, a national database. If a dollar value is not available in the national database, the TPA will consider 75% of the billed charge as the MPA. In certain instances, when a dollar value is not available in the database, the claim is reviewed by the TPA’ medical consultant, who determines a comparable code to the one billed. Once a comparable code is established, the claim is processed as described above. MPA for Emergency Services by an Out-of-Network facility will be processed as follows: the maximum amount allowed will be is the greatest of the median In-Network rate, the maximum amount as calculated according to this definition for Out-of- Network facility, and the Medicare allowable amount. When using an